Periodontology 2000, Vol 33, 2003,67-81. Management of the posterior maxilla in the compromised patient: historical, current, and future perspectives Thomas J. Balshi & Glenn J. Wolfinger The posterior maxilla has been described as the most appearance. One solution has been the use of posterior difficult and problematic intraoral area confronting the cantilevers on implant prostheses. When designed to implant practitioner, requiring a maximum of ingenuity minimize the occlusal forces applied to the pontic, short for the achievement of successful results(39, 59). Both cantilevers can function successfully. One key is the anatomical features and mastication dynamics contribute availability of several long and strong implants anterior to the challenge of placing titanium implants in this to the cantilever. The author also suggests the use of region. implants of 4mm diameter or greater, if the intent is to create a cantilevered prosthesis. Anatomic factors include decreased bone quantity, especially in older edentulous or partially edentulous If sufficiently strong anchors are unavailable or longer patients who have experienced alveolar resorption in the cantilevers are required, problems are likely to ensue. wake of tooth loss. The antrum also tends to enlarge Complications associated with posterior cantilevers with age, as well as with edentulism, and this further include screw loosening and fracture, bone loss around decreases the amount of available bone. In addition to the most distal fixtures, and loss of osseointegration(7) the diminished quantity, bone in the posterior maxilla (Figure 1). As awareness of such consequences has often is softer and of poorer quality. Radiographs grown, the alternative of creating non-cantilevered bone- typically reveal a dearth of trabeculations, and the tactile anchored restorations has become increasingly desirable. experience of drilling here often more closely resembles the penetration of styrofoam rather than anthracite. The following discussion reviews the development of Limited access to the pterygomaxillary region implant solutions in the posterior maxilla and examines constitutes yet another problem. the feasibility of applying these solutions to the compromised patient. Future prospects are also briefly Mastication dynamics also affect the long-term stability assessed. of implants placed in the posterior maxilla. Whereas masticatory forces of 155N have been reported in the Standard Implant Placement incisor region, the premolar and molar regions have exhibited forces of 288N and 565N, respectively(3). Studies of the long-term success of osseointegrated Parafunction can increase these forces as much as three- implants placed in the posterior maxilla have painted a fold(4-6), applying significant stress to the bone-implant mixed picture. Jaffin and Berman, reporting specifically interface and the component hardware. on implants used in this region(8), noted a higher failure rate related to Type IV bone. Schnitman(9) showed that Despite the biomechanical impediments to creating only 72 percent of implants placed in the posterior prostheses in the posterior maxilla, patients who have maxilla achieved osseointegration. When Widmark et al lost teeth in this area have sought some means of studied the results of implants placed in the severely restoring both their chewing ability and their resorbed maxillae 67 Balshi & Wolfinger (a1) (a2) Figure 1 (a) Panoramic and periapical radiographs of maxillary fixed (b1) (b2) detachable prosthesis with cantilever illustrating advanced bone loss on posterior fixture. (b) Transition from fixed detachable prosthesis to maxillary implant overdenture one five implants after removal of three posterior implants with advanced bone loss. Note the bone loss on the remaining implants as well. (1c) Additional fixtures placed in the pterygoid region for extension of the overdenture bar for better stability. (b) of 36 patients (16 of whom received bone grafting and 20 94.4 percent at five to six years and a 93.4 percent rate of whom did not), they found that after three to five after 10 years. Lazzara and coworkers found a success years, the success rates in the two groups were 74% and rate of 93.8 percent among 529 implants placed in the 87%, respectively10. posterior maxilla12. The Kaplan-Meier success rate for 167 IMZ posterior maxillary implants after 80 months Other investigators, however, have found significantly was 96.9 percent, according to Haas and colleagues(13). higher success rates. Bahat(11), analyzing the experience And when Buchs and associates studied Steri-Oss HA- with 660 Brånemark System implants placed in the coated threaded implants, including 416 placed in the posterior maxilla and followed in 202 patients for up to posterior maxilla, their life-table analysis indicated a 12 years after loading, found a cumulative success rate of 96.6 percent five-year success rate(14). 68 Management of the posterior maxilla Figure 1. continued A number of recommendations for achieving predictable implant osseointegration in the posterior maxilla have Hard-Tissue Grafting in Conjunction been made. To obtain a greater surface area for bone with Standard Implants contact, Langer et al suggested the use of wider diameter implants(15). More recently, Bahat recommended When standard implant placement is contraindicated placement of a sufficient number of implants to support because of inadequate bony volume, one approach the occlusal load in a way that avoids nonaxial historically has been to augment the ridge. Breine and loading(11). Brånemark first described the use of onlay composite bone grafts for reconstruction of compromised severely In the author's experience, standard implant placement in atrophic ridges in 1980(19). Although the original the posterior maxilla is indicated if at least 8mm of bone technique has evolved considerably since then, is available below the sinus. In such cases, a 10mm unpredictable resorption of the graft material has been a implant can be utilized. The apical threads of the implant continuing problem(20). Verhoeven et al, assessing will engage the layer of cortical bone that forms the various studies of onlay grafts, sandwich osteotomies, antral floor, thereby creating bi-cortical stabilization of and onlay grafts plus hydroxyapatite augmentation, the fixture and a slight apical tenting of the sinus found that in the first year after bone grafting, resorption membrane. This tenting, or mini sinus lift, is similar in is significant and may continue for up to three years(21). effect to the osteotome technique for fixture placement(16). Even when successful, grafting of the ridge may reduce the posterior interocclusal space so significantly as to Another alternative is to utilize longer implants, tilting cause prosthetic restorative problems(22). Another them anteriorly between the floor of the sinus and the approach, therefore, has been to augment the floor of the apex of the canine or other anterior teeth. Such off-axis sinus. Introduced by Dr. Hilt Tatum in 1975(23), the loading of maxillary anterior implants has been sinus lift graft has gradually gained proponents over the shown(17,18) to achieve osseointegration and create a years, and a 1996 consensus conference on sinus grafts stable support system for the prosthesis. organized by the Academy of Osseointegration found that sinus grafting should be considered a highly Immediate extraction sites also offer opportunities for predictable and effective therapeutic modality(24). standard implant placement in the posterior maxilla because residual bone usually exists around the Today two basic sinus grafting strategies exist. In the extraction site. first, elevation of the sinus and placement of the implants occur simultaneously. This approach offers the When standard implants are placed in the posterior advantage of requiring fewer surgeries, while at the same maxilla of partially edentulous patients, the final time allowing for a shorter treatment time and reduced prosthesis will not enjoy the benefit of cross-arch expense. However, at least 5mm of bone must be present stabilization. Therefore, more implants are recommended in order to ensure rigid fixation of the implant at the time to prevent the overload bending moment forces that can of placement(25) (Figure 3). cause bone loss around the implants (Figure 2). 69 Balshi & Wolfinger commitment of close to two years, a prospect that is unattractive to many patients. Furthermore, all grafting may result in complications, including infection and loss of grafted bone. As a result, placement of implants in more distant support sites in the maxilla has emerged as another potentially attractive alternative. Tuberosity and Pterygoid Implants (a) There has been a longstanding feeling among clinicians that the pterygomaxillary region of the maxilla was unsuitable for implants because of large fatty marrow spaces, limited trabecular bone, and the rare presence of cortical bone covering the alveolus. However, subsequent clinical trials showed that titanium fixtures could successfully osseointegrate in this area(26-27). Indeed, the density of some of the pterygomaxillary structures may provide stability that exceeds that offered by the anchorage in any other part of the maxilla(28). Reiser's anatomic investigations using cadaver dissection have shown that the specific structures that may support (b) implants are the tuberosity of the maxillary bone, the pyramidal process of the palatine, and the pterygoid process of the sphenoid